Thursday, March 10, 2016

Next Steps: Intervention for Advanced Learners


Photo source: www.ciam.edu, www.shootthecenterfold.com


*Note: This post is Part II of a Two Part series.

Disclaimer Time :-)

ABA treatments or interventions are not one size fits all, and should never follow a generic formula across individuals. The specific needs and strengths of the individual receiving services will always guide treatment planning and intervention choices. This post is meant to be a helpful guide, not a guaranteed "recipe" to designing intervention.

End of disclaimer.

We already reviewed the challenges of designing intervention for early learners/individuals who are new to therapy. Now let's talk about the challenges of designing intervention for the advanced learners, or those who are only mildly impacted by their diagnosis.

To make sure we're are all on the same page, what do I mean when I say an advanced learner?

  • Typically older, or if younger this is an individual who is only mildly impacted by their diagnosis (e.g. Asperger's)
  • Typically in a regular education classroom with some supports. If this type of child IS in a self- contained room, it is usually only because of problem behavior
  • Deficits are NOT pervasive; the individual may be on grade level academically, but struggles with self-help skills. Or the individual may have appropriate use of language/be conversational, but has meltdowns on a daily basis
  • Typically this individual has problems with communication only when escalated. The ability to communicate, yet the likelihood to aggress when upset, can be highly frustrating to parents/teachers
  • Interest in peers, age appropriate toys, or social interaction can often be quite typical. Sadly there can be a strong desire/interest to be social but significant social deficits that stigmatize the child from peers
  • Problem behavior rate and severity can range from mild to high. This type of individual may be described as "moody". When they are calm and cooperative, they are a joy to work with/hang out with. However when they escalate, they can escalate quickly and take a long time to de-escalate  
For those of you who will be designing intervention, this type of child is way-y-y past the VB - MAPP, and may have filled up most of the grid on the ABLLS-R. We are way past Matching, Gross Motor Imitation, and Stacking Blocks with this kind of learner.

When I first meet an advanced learner, what usually strikes me is my initial thought of "Wow, why in the world are we working with this kid???". This is the type of client who will greet you, strike up a conversation, excitedly show you their room and their toys, and proudly tell you they just got an A on a science report. But then.......you start to notice some things. Like the child is 9, and the parents report he wears Pull Ups at night. Or the child is 13, and her best friend is the 4 year old girl across the street. Or the individual is 22, and won't leave the house without their pink Dora backpack.


 Many of you are nodding in agreement right now, because you have also had that "A-ha" moment where you realize that what appears to be a completely well functioning individual is actually someone in need of intervention and assistance.
Its a bit unfair, but I find that my advanced learner clients tend to irritate their caregivers and teachers the most. There is an expectation of self-management that just is not being lived up to.
 So what's the deal here?? How can you be so high functioning in some areas, yet so low functioning in other areas?

Its really simple, and I find myself explaining this to related professionals quite often. It is critical not to lower your expectations of early learners, or to raise your expectations of advanced learners. Simple.
It frustrates me, but I come across people all the time who don't expect much out of my early learner clients. Or the exact opposite: people who think just because my client with ASD can talk and be sociable, that they have NO other problems. Both are unfair, inaccurate, and completely ignore the unique strengths and deficits of the individual. ASD is a spectrum: expect variety.

I don't get to work with older, or more advanced learners very often, but when I do its so fun :-)
There are so many areas of programming you explore with a higher functioning client (cooking, vocational skills, shopping/making purchases, science projects/arts & crafts, manners/etiquette) and these types of clients will also entertain you during the therapy session. Like one client who noticed I had changed my hair color, and promptly told me I looked like Ariel from Little Mermaid. Or another client who told me she was going to call the police on me if I didn't stop making her do work. Or a 7 year old who asked me if I liked rap music, and when I said "no" he told me "Its okay, you'll like it one day when you get cool".


 Below is a sample of the intervention package for one of my previous advanced learner clients, including typical (see disclaimer) program goals.

Keep in mind that these recommendations are not setting specific. In other words, advanced learners will likely need these structures in place whether intervention takes place at home, at an ABA clinic, in a classroom, or at a work site. Changing the setting does not change what these individuals need to be successful.


Sample Intervention Package 

Teacher to Student Staffing Ratio:
Group Instruction (if aggressive, a 1:1 aide may be necessary)
Teaching Format:
Mostly Natural Environment Teaching,
Incidental Learning, and Community Based Instruction
Recommended Intensity:
8-15 hours per week
Reinforcement Schedule:
Variable or fixed interval schedule, for example 25:1 (one break every 25 minutes)
Types of Reinforcement:
Naturally occurring reinforcement (bake a cake, then eat it) should be provided on a thin schedule, as well as Token Economy systems
 Intervention Goals:
Community Outings, Intraverbal Associations, Socio-Dramatic Play, Hygiene, Sight Words, Reading Comprehension, Math Fluency Drills, Sportsmanship, Accepting Change, Resolving Conflict, Social Stories, Chores, Preparing Meals
Watch Out For These:
Over prompting/promoting rote responding (this is why DTT with this individual is not recommended), client curiosity about therapy progress, "splinter skills" learning profile, teaching should include adult, peer, and self-provided reinforcement, don't forget to teach self-management of behavior/self-evaluation of goals, for older clients physical management training for staff becomes vital,  inappropriate play/leisure interests (avoid social stigma)

4 comments:

  1. Why is client curiosity about therapy progress bad?

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    1. Really good question. The last box of the chart is not a list of things that are "bad". Its a list of things to watch out for/be aware of.

      I have worked with older clients who may obsess over their data for the session, and I've had to teach the staff to work at being more discreet with data collection. The client may see that he got a 40% on a target, and that could lead to an aggressive outburst or escalation.
      Also, some of my older clients have referred to the ABA team as their "friends" and we have had to explain why we work with them, and what our role is. So by curiosity I mean be prepared to explain and talk about things that an early learner client would not be able to ask, or just wouldn't be concerned with. I think its a good thing to explain what the process is and what is going on to the client when they show that curiosity.

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  2. Dear Tameika,

    What a joy to read your posts. My kid, just turned 3, is a great manipulator, and probably a mildly affected kid. When he finds the "right therapist" (usually the supervisor, or someone highly experienced), he learns in the speed of light. His cognition is of a four year old, and he is starting to become conversational, and can answer to many questions, play pretend and is very social.
    Once he senses any hesitation in a new therapist, he uses all sorts of manipulation techniques to drive her bonkers. It literally goes like this: supervisor and new therapist work together for 2 hours. My son completes every task 100%, speaks in full sentences, and obeys with a big smile. The supervisor leaves. My child is on the floor, screaming "therapy is all done", "I don't want play"...giving her zero chance of success.
    Discreet methods do not work for him, as he is very socially aware and very stubburn...I often have the stares of moms of ASD kids, who are clearly more affected in cognition and language, stare at my disobedient child as if he is in really bad shape.

    Do you have advise on how to work with this type of kids of you are brand new ABA therapist? Is there a way to work with supervisor more often, or the insurance won't allow?

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    Replies
    1. Thanks for your comment!

      Much of what you are describing sounds behavioral, and not necessarily like a unique learner profile. Meaning that the supervisor should be able to provide more training to the staff on a consistent behavior plan, combined with increasing reinforcement to "pair" the staff with your child. Since your son works just fine for the supervisor, it sounds like he is already paired just fine with her or him.

      It is hard to say what the supervisor can do, as I do not know the specifics of your situation. For example, if the insurance approves 8 hours of supervision a month, then that is all you get...period. So it really depends on your funding source, the availability of your supervisor, and if you can request more experienced staff/Masters level staff.

      If possible, discuss your concerns with the supervisor and company owner and see what options you have to resolve this issue. Good luck to you!

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